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Pregledni Ëlanak / Review article
Trauma srca (tamponada srca-perikarda)
Cardiac Trauma (cardiac-pericardium tamponade)
Greta CindriÊ Bogdan*
Kardioloπka poliklinika “Bogdan”, Zagreb, Hrvatska
Bogdan Cardiology Polyclinic, Zagreb, Croatia
SAÆETAK: Prikazani su najËeπÊi uzroci traume srca s
posebnim osvrtom i definicijom nepenetrantne — tupe i
penetrantne — oπtre ozljede, obje Ëeste u tijeku traume
prsnog koπa. Opisane su tamponada srca i kontuzija
miokarda. Navedeni su simptomi, kliniËka slika, patomorfoloπka-patofizioloπka zbivanja oba entiteta. Ukazano je na vaænost brze intervencije na mjestu nesreÊe,
incidenta, osobito kod penetrantne traume srca. Istaknuti su znaËenje prehospitalne skrbi za pacijenta kao i
potreba visoke struËnosti ekipe hitne medicinske pomoÊi
uz primjenu transtorakalnog ehokardiografskog pregleda na mjestu incidenta. Naglaπena je potreba da se uz
ehokardiografiju primijeni i terapijska perikardiocenteza
kao vaæan zahvat na mjestu incidenta, ali s velikim oprezom u pojedinoj penetrantnoj ozljedi srca, u cilju sprjeËavanja razvitka tamponade srca. Istaknute su dijagnostiËke moguÊnosti instrumentalnih pretraga srca i prsnog
koπa u hospitalnom razdoblju, u ocjeni osobito tupe —
nepenetrantne traume srca.
KLJU»NE RIJE»I: trauma srca, tamponada perikarda,
transtorakalna ehokardiografija, terapijska perikardiocenteza.
SUMMARY: The most common causes of cardiac trauma, with special regard to nonpenetrating — blunt and
penetrating — sharp injuries, frequent in the course of
thoracal injury, and their definitions are presented. Symptoms, clinical course and patomorphologic-pathophysiological events in cardiac tamponade and myocardial
contusion are described. The importance of rapid intervention at the spot, especially in penetrating cardiac
trauma is stressed. Special significance is given to prehospital care and accordingly the need for highly educated teams of first aid with the application of transthoracic
echocardiography on the spot of the incident as diagnostic method. Beside echocardiography, a need for careful application of therapeutic pericardiocentesis as urgent intervention as an important procedure at the place
of accident with the aim of prevention of fatal outcome
due to pericardial tamponade is strongly pointed. Diagnostic possibilities of instrumental heart and thorax
check-ups during hospital stay, especially in evaluation
of blunt — nonpenetrating cardiac trauma is described.
KEYWORDS: cardiac trauma, pericardial tamponade,
transthoracic echocardiogragraphy, therapeutic cardiocentesis.
CITATION: Cardiol Croat. 2013;8(10-11):331-344.
Uvod
Introduction
Ovaj je pregled potaknut epidemijom prometnih nesreÊa
motornim vozilima u Hrvatskoj s traumom prsnog koπa i srca
te uËestalim smrtnim ishodom kod nekih sportova kod kojih
postoji i trauma prsnog koπa, pa time i moguÊnost traume srca. PoveÊana uËestalost traume srca je ËeπÊa u naπim druπtveno-gospodarskim uvjetima æivota joπ uvijek i primjenom
hladnog oruæja. Ova problematika se ne moæe zanemariti
obzirom na uËestalost posjedovanja vatrenog oruæja buduÊi
to predstavlja potencijalni pojedinaËni izvor penetrantnih srËanih ozljeda sa smrtnim ishodom.
Smatra se da je oko 25% svih traumatskih ozljeda prsnog
koπa koje zavrπavaju smrtno uzrokovano upravo oπteÊenjem srca1. StatistiËki podaci pokazuju da je najËeπÊe zahvaÊena desna klijetka (DV; u 35%), a potom slijede lijeva
kljetka (LV; u 25%), desna pretklijetka (DA; u 33%) te lijeva
pretklijetka (LA; u 14%)1. Drugi statistiËki podaci iznose incidenciju oπteÊenja desnog dijela srca kod traume srca od
This review has been prompted by an epidemic of car accidents in Croatia with thoracic and cardiac trauma and frequent fatal outcome in some sports associated with thoracic
trauma, and thus the possibility of cardiac trauma. An increased incidence of cardiac trauma is more common in our
socio-economic living conditions still due to using cold weapons. This problem can not be ignored considering the prevalence of possession of firearms which is a potential individual source of penetrating cardiac injuries with fatal outcome.
The exact cause of about 25% of all thoracic traumas with
deadly outcome is the cardiac injury1. Statistical data show
that the right ventricle (RV; in 35%) is the most frequently
affected, followed by left ventricle (LV; in 25%), the right atrium (RA; in 33%) and the left atrium (LA; in 14%)1. Some other statistical data report on the incidence of injury of the
right part of the heart in cardiac trauma of 76% and left part
of 14.3%2. In addition to the cardiac injury, thoracic trauma
2013;8(10-11):331.
Cardiologia CROATICA
76%, a lijevog od 14,3%2. Uz oπteÊenje srca kod traume prsnog koπa Ëesto je prisutno i oπteÊenje drugih organskih sustava: pluÊa, pleure, medijastinuma, traheje, bronha, ezofagusa, rebara, aortne stijenke, kraljeænice, πto doprinosi nastanku kompleksne simptomatologije te stvara diferencijalno
dijagnostiËke poteπkoÊe1,3-5.
IzvjeπÊa svjetskih traumatoloπkih centara osim potrebe neposredne hitne intervencije “na licu mjesta” naglaπavaju
vaænost brze informiranosti i spremnosti ekipe kirurπkog
centra, πto bi trebalo omoguÊiti uËinkovitu hospitalnu intervenciju.
Usprkos neposrednoj pomoÊi i hitnoj intervenciji na mjestu
incidenta, a potom analize te hospitalnog lijeËenja, traumatsko oπteÊenje srËanih struktura s tamponadom perikarda i
dalje ima visoku incidenciju smrtnosti u prometnim nesreÊama — 20 %6. Na intervenciju kod penetrantnih ozljeda srca
u kirurπkim centrima otpada mali broj, svega 0,5% svih kirurπkh intervencija5. »ini se da mnogi pacijenti ne stignu do
struËne specijalistiËke pomoÊi, a uzrok tome je moæda i Ëinjenica da hitna medicinska pomoÊ na terenu nije opskrbljena adekvatnom aparaturom ili nije u stanju dijagnosticirati i
pruæiti adekvatnu pomoÊ. Traume srca — nepenetrantne i
penetrantne, u nesreÊama s motornim vozilima se javljaju u
visokoj zajedniËkoj incidenciji od 80% do 90%6,7. Nepenetrantne ozljede ne moraju biti odmah smrtonosne, ali se u
daljnjem praÊenju Ëesto kompliciraju loπim ishodom, a smrtnost u duljem posthospitalnom periodu takoer je visokih
57% do 64%8.
is usually accompanied by an injury of other organ systems:
lungs, pleura, mediastinum, trachea, bronchus, esophagus,
ribs, aortic wall, spine, contributing to the occurrence of
complex symptomatology and causing differential diagnostic
difficulties1,3-5.
Reports of international trauma centers emphasize not only
a need for direct emergency intervention “on the spot” but
also the importance of timely awareness and preparedness
of a surgical center team, which should allow for efficient inhospital intervention.
Despite direct assistance and emergency intervention on
the spot of the incident, followed by the analysis and in-hospital treatment, traumatic injury of cardiac structures with pericardial tamponade still shows a high incidence of deaths in
traffic accidents — 20%6. There is a small number of interventions in case of penetrating cardiac injuries in surgical
centers, only 0.5% of all surgical interventions5. It seems
that many patients come late for professional specialist
assistance, and the reason for this may be the fact that the
emergency medical assistance in the field is not equipped
with suitable apparatus or is unable to diagnose and provide
an appropriate assistance. Cardiac traumas — both nonpenetrating and penetrating, in car accidents show a high
common incidence from 80% to 90%6,7. Non-penetrating injuries may not be immediately fatal, but the further follow-up
often reveals complications followed by poor outcome thereby recording a high mortality over a longer post hospital period from 57% to 64%8.
Definicija i uzroci
Definitions and causes
SrËana trauma se dijeli na:
• nepenetrantnu — tupu povredu srca — bez neposredno
vidljivog oπteÊenja (rane, laceracije) na prsnom koπu, ali moguÊe posredno utvrenim kasnije unutraπnjim oπteÊenjima
na srcu, aorti i ev. drugim organima;
• akutnu penetrantnu — oπtru povredu srca (ranu), uz
manju ili veÊu ranu, razderotinu, laceraciju prsnog koπa, koja
je neposredno najËeπÊe i vidljiva.
Cardiac trauma is divided in:
• non-penetrating — blunt cardiac injury — without a direct visible injury (wounds, lacerations) in the chest, but later
internal injury of the heart, aorta and any other organs can
be indirectly determined;
• acute penetrating — sharp cardiac (wound) injury, with
a smaller or larger wound, tear, chest laceration, which is
directly usually visible.
Nepenetrantna povreda srca
Non-penetrating cardiac injury
Kod tupe traume dolazi do nagnjeËenja prsnog koπa, srca,
krvnih æila (ev. i drugih organa) od sile tupog udarca, a πto
se moæe dalje komplicirati strukturnim promjenama srca,
perikarda, miokarda, srËanih valvula, korda tendineja, papilarnih miπiÊa, rijetko endokarda te pluÊa, aortne stijenke s
disekcijom i s arterijsko-venskim fistulama — nastalim npr.
kod rupture sinusa Valsalve aorte s lijevo-desnim shuntom
ili lijevo-lijevim shuntom u LA te rijetko shuntom u perikardijsku vreÊu ili rupturom descendentne aorte na mjestu ligamentum arteriosum Botalli (posljednje zbog akceleracijskih i
deceleracijskih sila oko osovine sigurnosnog pojasa u autu).
U prvi trenutak djelovanja, blage tupe sile, unesreÊeni moæe
biti bez veÊih smetnji. Stoga, tupa trauma Ëesto zahtijeva
duæe kliniËko praÊenje i monitoriranje EKG-om, ultrazvukom
srca, radioloπkim i drugim metodama.
12-kanalni EKG treba snimiti odmah i najmanje 24 sata monitorirati te hospitalno promatrati bolesnika 7 dana i kod
pretpostavljeno “lakπih kontuzija” te potom Ëiniti povremene
kontrolne analize (holter EKG i ultrazvuk srca) koje mogu
utvrditi (u kronicitetu) kasne promjene8,9. Tupu traumu blaæeg intenziteta bolesnik nekad i zaboravi, pogotovo ako su
prvi simptomi bili blagi — opÊa slabost i blaga substernalna
In case of blunt trauma, contusions of the chest, heart, blood
vessels (or any other organs) are caused by blunt force impact, which can further get complicated as a consequence
of structural changes to the heart, pericardium, myocardium,
heart valves, chordae tendineae, papillary muscles, rarely
endocardium and lungs, aortic wall with dissection and arterial-venous fistulas — occurred for instance in case of sinus
rupture of the Valsalva aorta with left-right shunt or left-left
shunt in LA and rarely shunt in the pericardial sac or rupture of the descending aorta at the point of ligamentum arteriosum Botalli (the latter due to acceleration and deceleration forces around the seat belt shaft in the car). At the first
moment of action of mild blunt force, the injured may feel no
major problems. Therefore, blunt trauma often requires
longer clinical follow-up and monitoring by ECG, echocardiography, radiological and other methods.
12-lead ECG should immediately record and should be monitoring a patient for at least 24 hours in the hospital even in
case of presumed “minor contusions” to be followed by periodic follow-up analyses (Holter ECG and echocardiography), which can identify (in the chronicity) late changes8,9.
Slight intensity blunt trauma will never be forgotten by a
patient, especially if the first symptoms were mild — general fatigue and slight substernal pain. However, various
Cardiologia CROATICA
2013;8(10-11):332.
bol. Meutim, u duljem su praÊenju Ëesto prisutne razliËite
aritmije, pa i ventrikulska tahikardija te smetnje provoenja
s pogibeljnim AV blokovima10. Rijetke su manifestacije srËane slabosti s globalnim padom kontraktilnosti miokarda, ako
nije bilo dokazanog opseænijeg oπteÊenja.
Tamponada perikarda je vrlo rijetka u tupoj ozljedi, ali moæe
ipak nastati djelovanjem nepenetrantne sile preko prsnog
koπa ili preko trbuπne πupljine. »eπÊe se javlja u situaciji
tupe traume — manji perikardijski izljev s polaganim
razvitkom, najËeπÊe kao serozno eksudativna reakcija (ne
hematoperikard), autoimunog uzroka nastanka. To su reakcije na minimalno oπteÊenje perikarda, poput postoperacijskog perikarditisa — perikardiotomiËki sindrom. Takav perikardijski izljev, obiËno manjeg volumena, ne ugroæava punjenje DV, a ako polagano dosegne veliËinu oko 200 mL
moæe kod bolesnika u naporu izazvati blagu tahikardiju i
zaduhu. PovlaËenjem eksudata mogu zaostati manje fibrinsko-fibrozne promjene unutar perikarda, bez znaËajnih hemodinamskiih implikacija (najËeπÊe bez konstrikcije). Iznimno rijetko tupa trauma uzrokuje neposredno naglu smrt, kada kontuzija miokarda dovede do rupture miokarda zbog
manje ili veÊe laceracije stijenke miokarda ili perikarda ili
zbog opseænije disekcije aortne stijenke ili kada se tupi udarac dogodi u tzv. vulnerabilnoj fazi srËane rezolucije.
Iako je manje ugroæavajuÊa od penetrantne traume, jaka sila
i kod takve ozljede moæe dovesti do oπteÊenja drugih organa, kao npr. do dijafragmalne hernije zbog nastale razderotine dijafragme s hernijacijom abdominalnog sadræaja u prsni koπ i time uËiniti pritisak -kompresiju na srËane πupljine,
ali i hernijaciju miokarda kroz manju razderotinu perikarda,
nastalu tupom silom4,8. Jaka tupa sila moæe preko prsnog
koπa i trbuπne stijenke izazvati rotaciju srca i tzv. “luksaciju”
Ëitavog srca iz njegovog sjediπta. Posljednje promjene treba
iskljuËiti u hospitalnom razdoblju, najbolje viπeslojnom kompjutoriziranom tomografijom (MSCT).
Uzroci tupe nepenetrantne traume su mnogobrojni, ËeπÊe
samo s posljediËnim nagnjeËenjem prsnog koπa i srca, a
rjee manjim ili veÊim rupturama srca i okolnih organa. To
se dogaa u prometnim nesreÊama zbog nagle deceleracije, neposredne kontuzije volanom vozila u sternum te u
mnogobrojnim kontuzijama prsnog koπa i trbuha kod prevrtanja vozila. »est uzrok kontuzije prsnog koπa i srca nadalje
je pad s visine na tlo kao ozljeda na radu, namjerni jaki “ubilaËki” udarci rukom u prsni koπ, nenamjerni jaki udarci loptom, sudar dvaju tijela u sportu, a u stoËarstvu npr. udarac
kopitom æivotinje u prsni koπ, pad kod jahanja æivotinja, pad
s motocikla, bicikla i sl. Kod lijeËniËke reanimacije Ëesto se
ne moæe izbjeÊi manje ili veÊe iatrogeno nagnjeËenje miokarda i perikarda, nekad i uz frakturu rebara (πto moæe izazvati i penetrantnu ozljedu). SljedeÊi uzroci su zraËni udari
— zraËni “blast” u neposrednoj blizini eksplozije bombe,
mine, s kompresijom sternuma i organa na kraljeænicu, ev.
vodeni “blast” ili druga kompresija toraksa izmeu dviju nestlaËivih — metalnih podloga.
Osim deceleracijskih sila kod zaustavljanja dvaju vozila,
stvaraju se nekad u nesreÊama i kod prevrtanja vozila i jake
akceleracijske sile, velike snage, koje mogu dovesti do “fleksije” prsnog koπa s manifestacijom sila rastezanja (stretching) i sila rotacije (twisting)1 te time do ozljeda srca i drugih organa u prsiπtu. UËestale elektrokardioverzije mogu u
terapijskim zahvatima biti uzrok mikropromjena na miokardu, edema miokarda, pa i manjih nekroza. SliËno vrijedi i za
nesretne udare izmjeniËnom elektriËnom strujom, a Ëini se i
za udare elektriciteta iz munje (groma). U sluËajevima tupe
traume srca podatke o jaËini miokardne ozljede moæe se
2013;8(10-11):333.
arrhythmias, including ventricular tachycardia and conduction disorders with fatal AV blocks are usually present over
a long follow-up period.10 Heart failure symptoms are rare
with a global decrease in myocardial contractility, if no extensive injury has been proved.
Pericardial tamponade is very rare in the blunt injury, but still
may be caused by non-penetrating forces through the chest
or abdominal cavity. It occurs more commonly in a situation
of blunt trauma — a smaller pericardial effusion with a slow
development, usually as a serous exudative reaction (not
hemopericardium) of autoimmune etiology. These are the
reactions to minimal injury of the pericardium, such as postsurgical pericarditis — postpericardiotomy syndrome. Such
a pericardial effusion, usually a smaller pericardial effusion,
does not endanger the LV filling, and if it slowly reaches the
size of approximately 200 mL it can cause mild tachycardia
and dyspnea in the patient in effort. The retreat of exudates
may lead to smaller fibrinous-fibrous changes that may remain within the pericardium, without significant hemodynamic implications (usually without constriction). Extremely rare blunt trauma causes a direct sudden death, when myocardial contusion causes myocardial rupture due to a minor
or major laceration of the myocardial or pericardial wall due
to a more extensive dissection of the aortic wall or when the
blunt impact occurs in the so-called vulnerable stage of cardiac resolution.
Although it is less life-threatening than penetrating trauma, a
strong force in case of such an injury may cause injury of
other organs, such as diaphragmatic hernia as a result of
diaphragmatic rupture with herniation of abdominal contents
into the chest causing thus pressure on — compression of
the cardiac cavities, but also myocardial herniation due to a
small pericardial rupture, resulting from a blunt force4,8. A
strong blunt force can cause rotation of the heart and the socalled “luxation” or the dislocation of the whole heart through
the chest and abdominal wall. The last changes need to be
excluded in the in-hospital period, best by using multi-layer
computed tomography (MSCT).
The causes of blunt non-penetrating trauma are multiple,
usually resulting in consequential chest and heart compression and rarely in minor or major ruptures of the heart and
surrounding organs. This happens in car accidents as a result of sudden deceleration, direct contusion of the sternum
by the steering wheel and numerous contusions of the chest
and abdomen in case of a car rollover. A common cause of
contusion of the chest and the heart is also a fall from the
height onto the ground as an occupational injury, intentional
strong “murderous” blows to the chest, unintentional fierce
hit by the ball, collision of two bodies in the sport, and in cattle breeding the kick by an animal’s hoof in the chest, falling
off a riding animal, falling off a motorcycle, bicycle, etc. Minor or major iatrogenic myocardial and pericardial contusion
cannot often be avoided in medical resuscitation, sometimes
accompanied by fractured ribs (which can cause a penetrating injury). The following causes are air strikes — air “blast”
in the immediate vicinity of the explosion of a bomb, mine,
with compression of the sternum and organs on the spine,
any water “blast” or other compression of the thorax between the two incompressible — metal substrates.
Besides the deceleration forces, when bringing two vehicles
to a halt a strong acceleration forces are created, sometimes even in accidents in a case of rollover. Such acceleration forces of high power can lead to “flexion” of the chest
with the manifestation of the stretching forces and twisting
forces1 and thus to the cardiac injury and injury of other
organs in the chest. Frequent electrocardioversions can in
therapeutic interventions be the cause of micro changes to
the myocardium, myocardial edema and minor necrosis.
The same applies to the unfortunate alternating electric current strikes, and probably to lightning strikes and electrical
discharge produced by the thunderstorm. In cases of blunt
Cardiologia CROATICA
dobiti odreivanjem specifiËnih miokardnih enzima i troponina.
cardiac trauma, the details on the severity of myocardial
injury can be obtained by determining specific myocardial
enzymes and troponin.
Akutna penetrantna povreda srca
Kod akutne penetrantne — oπtre ozljede posljedice djelovanja sila se oËituju odmah teπkim kardioloπkim smetnjama
i opÊim teπkim stanjem ozlijeenog, Ëesto s hipovolemiËkim
— uz oligemiju,Figure
hemoragiËnim
πokom (neki kliniËari hipo2.
volemiËki πok nazivaju i “opstruktivnim” — jer je sprijeËeno
of coronary
normalnoDistribution
punjenje srca
u dijastoli uz ev. opstrukciju velikih
artery
segments
stenoses.
æila) ili opÊenito traumatskim
πokom, πto zahtijeva πto hitniju, podrobniju dijagnozu i terapiju. Uzroci takve ozljede s
najËeπÊe trenutnim smrtnim ishodom i u mirnodopskim su
uvjetima i dalje projektili iz vatrenog oruæja, zrna veÊeg kalibra iz samokresa/piπtolja, “magnuma”, “beretke” ili viπe manjih zrna iz oruæja za lov “saËmarice”; namjerne ubodne rane
hladnim oruæjem, noæem; sluËajne ozljede oruem i drugim
oπtrim predmetima u industriji i proizvodnji. U prometnim nesreÊama dogaaju se veÊe razderotine, laceracije prsnog
koπa i prekid kontinuiteta struktura perikarda, miokarda, aorte, oπtrim rubovima frakturiranih rebara i sternuma, ozljedom
“leteÊim” oπtrim predmetima velikih brzina (akceleracijskih
sila) od stakla ili lima te nekad i samim jakim kompresijama
(s tlaËenjem izmeu sternuma, rebara i kraljeænice). Procjenjuje se da je kod takvih dogaanja incidencija teæih lacerirajuÊih oπteÊenja srca od oko 20%3, od kojih polovica zavrπava smrtno. U poljoprivrednim aktivnostima svjedoci smo
da je prevrtanje poljoprivrednih strojeva (traktora) gotovo
uvijek smrtonosno za vozaËa. Radi li se pri tome o srËanoj
smrti ili drugim uzrocima nije ispitano.
PenetrirajuÊa trauma srca u civilnom druπtvu sjeverne Amerike u Ëetvrtini sluËajeva (svih penetracija u prsa) i dalje je
uzrokovana noæem. U Turskoj je retrospektivnom analizom
od 2005. do 2008. god. pokazano da je 5% penetrantnih ozljeda uzrokovano zrnom iz vatrenog oruæja, a 95% ubodnih
rana hladnim oruæjem, oruem ili drugim11.
Premjeπtaj (displasman) trbuπnih organa u prsni koπ i obratno (samog srca prema trbuπnoj πupljini) preko rupturirane
dijafragme dovodi do hernijacije trbuπnih organa i nekad tzv.
“luksacije”, pomaka srca s nagnjeËenjem kao kod tupe traume ili/i s posljediËnom laceracijom, rupturom srca — miokarda, perikarda, disrupcijom srËanih valvula, papilarnih miπiÊa,
aorte i velikih vena. Ortopedski naziv “luksacija”, “iπËaπenje”,
izvrnuÊe iz primarnog poloæaja srca, kao i “volvulus” (zapletaj) — naziv iz abdominalne hitne kirurgije ovdje iznimno
imaju znaËenje zaokreta srca i velikih æila oko njihove osovine i mogu dovesti do opstrukcije vene kave inferior, velikih
arterija i kompresije desne strane srca i medijastinalnih organa1,12. OπteÊenja su usko povezana i s kompliciranom srËanom rupturom u 28% sluËajeva, Ëija smrtnost je visoka —
67%13. ZnaËajna promjena elektriËne osi na EKG-u u tim
situacijama (ako je poznat raniji nalaz) suspektna je uvijek
na “luksaciju” i premjeπtaj srca.
I u penetrantnoj ozljedi uz laceraciju miokarda, perikarda,
moæe istodobno postojati dodatno oπteÊenje miokardnih arterija, arteriola te preko ishemije dovesti do sekundarne nekroze i rupture miokarda ili opet neposredno zbog rupture
stijenke koronarnih arterija i spomenutih arteriola do hematoperikarda.
PenetrirajuÊa, prostrijelna i ubodna rana vidljivo oπteÊuju
prednji dio prsnog koπa (najËeπÊe na ulazu) te projektilom
(nevidljivo) velike æile, aortu, vene, medijastinum i kraljeænicu u kojoj se projektil moæe zaustaviti i prouzrokovati neuroloπke ispade. Projektil i ubodna rana mogu, meutim, biti
Acute penetrating cardiac injury
In acute penetrating — sharp injury the consequences of the
forces are immediately manifested by severe cardiac disorders and severe general condition of the injured, often with
hypovolemic — with oligemia, hemorrhagic shock (hypovolemic shock is called “obstructive shock” by some clinicians — because the normal filling of the heart in diastole
with potential obstruction of large vessels is prevented) or
generally with traumatic shock, which requires an urgent,
thorough diagnosis and therapy. The causes of such an injury usually with a deadly outcome are even at peacetime
still projectiles from firearms, larger caliber bullets from the
rifle/pistol “magnum”, “beret” or several smaller bullets from
the hunting “shotgun”; deliberate stab wounds by cold weapon, knife; accidental injuries by tools and other sharp objects in the industry and production. In traffic accidents major tears, chest lacerations and a break in the continuity of
the pericardial, myocardial, aorta structures which are caused by sharp edges of fractured ribs and sternum, an injury
by “flying” high speed sharp objects (acceleration force) of
glass or metal, and sometimes the very strong compressions (with compression between the sternum, ribs and spine) occur. It is estimated that the incidence of such events
in severe cardiac lacerations is about 20%3 of which a half
of them end up with a fatal outcome. In agricultural activities,
we have witnessed that overturning of agricultural machinery (tractors) is almost always fatal for a driver. It has not
been studied whether a cardiac death or some other causes
were the reason for death.
Penetrating cardiac trauma in the civil society of North America in a quarter of cases (of all penetrations into the chest)
is still caused by a knife. In Turkey, a retrospective analysis
conducted from 2005 to 2008, showed that 5% of penetrating injuries were caused by bullets from a firearm, and 95%
of stab wounds by a cold weapon, tools etc.11.
The displacement of abdominal organs in the chest and reversely (of the very heart towards the abdominal cavity) via
the ruptured diaphragm leads to herniation of abdominal
organs and sometimes the so called “luxation”, displacement of the heart with contusion as in blunt trauma or/and
with consequential laceration, rupture of the heart — myocardium, pericardium, disruption of cardiac valves, papillary
muscles, aortic and large veins. Orthopedic term “luxation”,
“dislocation” from the primary position of the heart, as well
as “volvulus” (obstruction) — the name taken from emergency abdominal surgery denote here rotation of the heart and
large vessels around their axis and can lead to obstruction
of the inferior vena cava, large arteries and compression of
the right side of the heart and mediastinal organs1,12. The injuries are closely associated with complicated cardiac rupture in 28% of cases, where mortality is high — 67%13. Significant changes in the electrical axis in ECG in these situations (if an earlier finding is known) are always suspicious for
“luxation” and “dislocation” of the heart.
The penetrating injury along with the myocardial, pericardial
laceration can be accompanied by additional injury of myocardial arteries and arterioles causing secondary necrosis
and myocardial rupture through ischemia or again directly
causing hemopericardium as a consequence of the rupture
of the walls of coronary arteries and above mentioned arterioles.
The penetrating, gunshot and stab wounds visibly damage
the anterior chest (usually at the entrance) and the missile
(invisibly) damage large vessels, aorta, veins, mediastinum,
and spine where the missile can stop and cause neurological injuries. The missile and stab wounds, however, can be
Cardiologia CROATICA
2013;8(10-11):334.
usmjereni iz trbuπne πupljine u pravcu srca, pa je tada ulazna rana na trbuπnoj stijenci, ponekad i sa straænje strane
prsiπta u leima, πto zahtijeva detaljan pregled da se rane
ne previde. LacerirajuÊa povreda srca moæe se dogoditi i
iznutra kod jakih kompresija (bez vidljive ulazne i izlazne rane) te kod nekih dijagnostiËkih i terapijskih kardioloπkih zahvata kao πto su: kateterizacije srca, ispitivanja provodnog
sustava srca, radiofrekventne ablacije provodnih puteva, postavljanja elektriËnog stimulatora srca, TAVI operacije aortne srËane greπke ili rekonstrukcije zalistka arterijskim ili venskim putem (kao npr. kod perkutane mitralne valvuloplastike, plastike trikuspidnog zalistka), biopsije miokarda, za vrijeme koronarografije s postavljanjem stentova ili/i tijekom
dilatacije koronarnih arterija.
directed from the abdominal cavity in direction of the heart,
and then the entry wound in the abdominal wall is sometimes in the posterior chest in the back, which requires a
detailed examination to prevent overlooking of the wound.
Cardiac laceration can even occur from the inside in case of
strong compressions (with no visible entry and exit wound)
and in some diagnostic and therapeutic cardiac procedures
such as: cardiac catheterization, examining the conduction
system of the heart, radiofrequency ablation of conductive
pathways, implantation of electrical pacemaker, TAVI procedures on the aortic heart valve defects or arterial or venous
valve repair (such as in percutaneous mitral valvuloplasty,
plastic procedure on the tricuspid valve), myocardial biopsy,
during coronary angiography with stent implantation and/or
during the dilation of coronary arteries.
Patofiziologija i kliniËka slika tamponade
perikarda
Pathophysiology and clinical course of
pericardial tamponade
Svaki perikardijski sadræaj uz nastalu akutnu oπtru traumu
srca treba smatrati hematoperikardom dok se ne dokaæe
suprotno, kao i potencijalnim uzrokom tamponade perikarda1,3,9,11,24. Hematoperikard zbog naglog nastanka i ovdje velike koliËine krvi u perikardijskoj πupljini bez intervencije gotovo uvijek prelazi u tamponadu. Stoga intervenciju, terapijsku perikardiocentezu, treba uËiniti πto prije, u intervenciji
ekipe hitne medicinske pomoÊi (HMP) na terenu incidenta,
osim kod ozbiljne sumnje da je hematoperikard uzrokovan
disekcijom aorte, kada je perikardiocenteza kontraindicirana.
Tamponada perikarda se ujedno smatra i ekvivalentom ponajprije penetrantne ozljede srca izvana (iako moæe nastati i
kod nepenetrantne ozljede) koja ne mora biti vidljiva kao
rana na povrπini prsnog koπa ili trbuha. StatistiËki podaci
ukazuju da neke ubodne rane hladnim oruæjem, uskim vrπkom noæa ili manje ubodne rane vrπkom frakturiranog rebra,
ivera sternuma imaju bolju prognozu od rana nastalih vatrenim oruæjem. Nastanak tamponade perikarda u prvom
sluËaju je obiËno postupniji, polaganiji, a mala rana ili rana
uzduænog rasjeka miokarda i perikarda nekada se stisne,
suzi te moæe i spontano trombozirati. OπteÊenje miokarda
velikim projektilom dovodi naglo do tamponade velikom koliËinom hemoperikarda, a ukoliko nema intervencije, Ëesto i
do brzog smrtnog ishoda.
Na procjeni koliËine perikardijskog sadræaja neposredno nakon incidenta veÊ su 1999. god. inzistirali japanski autori primjenom ultrazvuka srca i intervencijom9. Perikard nije rastezljiv, osim u postupnom poveÊanju perikardijskog sadræaja
(hipotireoza, uremija) kada se moæe poveÊati volumen perikardijske vreÊe sve do 1.500-2.000 mL, bez znaËajnih
simptoma u mirovanju. Ako se perikardijski sadræaj poveÊa
naglo, nekad i 100mL krvi moæe uzrokovati simptome tamponade.
Naglim poveÊanjem volumena u perikardijskoj vreÊi raste
intraperikardijski tlak. Kada se tlak u perikardu pribliæi tlaku
u DA, funkcija DV je bitno oπteÊena. Poviπeni intraperikardijski tlak ometa nadalje dijastoliËko πirenje klijetki. To vodi
daljem poveÊanju intrakavitarnog dijastoliËkog tlaka i smanjuje punjenje klijetke (u poËetku viπe DV, potom i LV), a
time se bitno smanjuju udarni i minutni volumen lijeve strane
srca i pada sustavni arterijski tlak. Porast intraperikardijskog
tlaka je u upravnoj korelaciji i s porastom sustavnog venskog tlaka i tlaka u pluÊnim venama te posljediËno dovodi do
spomenutog porasta tlaka u DA, ali i u LA. Zbog porasta
sustavnog venskog tlaka i tlaka u pluÊnim venama, dijastoliËkog tlaka u obje komore, dijastoliËkog tlaka i u pluÊnoj
Each pericardial fluid with sharp cardiac trauma should be
considered hemopericardium unless proven otherwise, and
also the potential cause of pericardial tamponade1,3,9,11,24. Due
to its sudden occurrence and here large amounts of blood in
the pericardial cavity, hemopericardium develops almost always to tamponade if no intervention is performed. Therefore, the intervention, therapeutic pericardiocentesis should
be performed as soon as possible by the emergency medical services (EMS) on the spot of the incident, except in
case when reasonably suspecting that hemopericardium is
caused by aortic dissection, when pericardiocentesis is contraindicated.
Pericardial tamponade is also considered equivalent primarily to penetrating cardiac injury from the outside (although it
can occur in case of non-penetrating injury) that may not be
visible as a wound on the surface of the chest or abdomen.
The statistical data show that some stab wounds caused by
cold weapons, a narrow tip of a knife or minor stab wounds
caused by a tip of a fractured rib, body of sternum have a
better prognosis than the gunshot wounds. The pericardial
tamponade in the first case usually occurs more gradually,
slowly, and a minor wound or a longitudinal myocardial or
pericardial rupture wound is sometimes squeezed, narrowed and can spontaneously thrombosed. Myocardial injury
by a large missile causes a sudden tamponade by a large
amount of hemopericardium, and a fatal outcome if no intervention is performed.
The Japanese authors insisted on the assessment of the
amount of pericardial fluid immediately after the incident in
1999 by using the heart ultrasound and intervention9. Pericardium may not stretch, except in gradual increase in pericardial fluid (hypothyroidism, uremia) when the volume of
pericardial sac can increase up to 1,500-2,000 mL without
significant symptoms at rest. If the pericardial fluid increases all of a sudden, sometimes 100mL of blood, can cause
symptoms of tamponade.
A sudden increase in volume in pericardial sac increases intrapericardial pressure. When the pressure in the pericardium becomes close to the pressure in the RA, RV function is
then significantly impaired. Elevated intrapericardial pressure hinders further ventricular diastolic expansion. This
leads to a further elevation of intracavitary diastolic pressure
and reduces ventricular filling (initially more RV, followed by
LV), thus significantly reducing the stroke and minute volume of the left side of the heart whereas the systemic arterial
pressure drops. The elevation of the intrapericardial pressure administratively correlates to an elevation of the systemic venous pressure and the pressure in the pulmonary
veins consequently leading to the aforementioned elevation
of pressure not only in the RA, but also in LA. The elevated
systemic venous pressure and pulmonary venous pressure,
2013;8(10-11):335.
Cardiologia CROATICA
arteriji, rastu vrijednosti tlaka u srcu na pribliæno istu razinu:
nestaju intrakavitarne i intravaskularne razlike tlaka i nastaje stanje tamponade perikarda s daljnjim padom udarnog
volumena, padom arterijskog tlaka i preko cirkulacijskog kolapsa dolazi do kardiogenog πoka, najËeπÊe sa smrtnim
ishodom.
Moæe se zakljuËiti da tamponadu perikarda patofizioloπki karakterizira:
1. poveÊanje intrakardijskih tlakova uzrokovano naglim poveÊanjem intraperikardijskog tlaka,
2. ograniËeno punjenje srËanih komora u dijastoli,
3. redukcija udarnog i minutnog volumena srca.
KliniËku simptomatologiju tamponade Ëini u poËetku jaka
prsna bol substernalno te epigastriËno (vezana najËeπÊe uz
lacerirajuÊu ozljedu), potom opÊe teπko prostrirajuÊe stanje
s bljedoÊom, zaduhom, tahipnejom, tahikardijom, a ponekad
u poËetku i disfagijom, kaπljem, promukloπÊu zbog Ëesto jake kompresije pluÊa, bronha i rekurentnog æivca. Na kraju
dominira slika πoka.
Fizikalnim pregledom se utvrde tipiËni znakovi tamponade:
1. sustavna hipotenzija (mali udarni i minutni volumen);
2. distenzija jugularnih vena kao znak nemoguÊnosti punjenja DV i poviπenja tlaka u desnom dijelu srca i venskom sustavu;
3. mukli ili neËujni srËani tonovi (uz tahikardiju) — sve nazvano karakteristiËnim Beckovim trijasom14.
Gotovo je uvijek prisutna spomenuta tahikardija zbog kompenzatorne simpatikotonije i kateholaminemije, kao reakcija
na pad udarnog volumena i doæivljenu traumu; tahipneja
(kompresija pluÊa, bronha, hipoksija), blijedoÊa koæe i sluznica te ev. periferna cijanoza. Perikardijsko trenje kod veÊeg
se izljeva ne Ëuje. VeÊi hematoperikard komprimira lijevo
pluÊno krilo, πto se perkutorno oËituje muklinom, a auskultatorno neËujnim disanjem (Ewartov znak). InaËe nema fizikalnih znakova zastoja u pluÊima πto je karakteristiËno. Arterijski tlak je nizak — oko ili ispod 90 mmHg. Kada bi se mjerio venski tlak u kubitalnoj veni, bio bi poviπen.
Moæe biti prisutan tipiËan Kussmaulov znak, koji se oËituje
smanjenjem distenzije vratnih vena u inspiriju (a koji nije izraæen u teæoj hipovolemiji) te karakteristiËan tzv. paradoksni
nalaz pulsa, ev. uz pad tlaka. Paradoksni puls je usporenje
frekvencije srca u inspiriju (normalno je ubrzanje), a πto se
teπko moæe kliniËki ocijeniti u prisutnoj tahipneji. Arterijski
tlak mjeren u inspiriju trebao bi pasti takoer za 15-20 mmHg
da se znak prihvati pozitivnim za tamponadu (πto neki kliniËari takoer svrstavaju u paradoksnost). Pad tlaka u inspiriju je inaËe normalno prisutan u zdravih individua ali i u nekim
drugim bolestima, pa se sensu stricto ne moæe taj pad nazvati visoko specifiËnim paradoksnim znakom.
Smanjenje distenzije jugularnih vena u inspiriju je znak kratkotrajnog sniæenja tlaka u DA i intraperikardijski zbog kratkotrajno nastalog negativnog tlaka u prsnom koπu. To omoguÊuje samo kratkotrajno punjenje DV i kratkotrajno poveÊanje dimenzija kaviteta DV u inspiriju.
Za tamponadu i oπteÊenje perikarda nema patognomoniËnog EKG znaka, ali se ponekad moæe utvrditi viπe znaËajnih:
1. elevacija ST-spojnice, na vrhu tipiËno konkavna; 2. elektriËni alternans; 3. niska voltaæa amplituda QRS-kompleksa
(zbroj amplituda u D1, D2, D3 manje od 15 mm). Posljednji
je takoer neosjetljiv i nespecifiËan znak tzv. “kratkog spoja”
u putovanju elektriËnog impulsa kroz perikardijski izljev, jer
Cardiologia CROATICA
diastolic blood in the both chambers, diastolic pressure in
the pulmonary artery lead to an elevation of pressure values
in the heart at approximately the same level: intracavitary
and intravascular pressure differences disappear resulting
in the condition of pericardial tamponade with a further drop
in stroke volume, drop in blood pressure and via circulatory
collapse causing cardiogenic shock, often with a fatal outcome.
It can be concluded that pericardial tamponade is pathophysiologically characterized by:
1. elevation of intracardiac pressures caused by sudden elevation of intrapericardial pressure;
2. limited diastolic filling of cardiac chambers;
3. reduction of cardiac stroke and minute volume.
Clinical symptomatology of tamponade is at first manifested
as a strong substernal and epigastric chest pain (usually
associated with laceration-related injury), followed by the
general serious prostrate condition with pallor, dyspnea, tachypnea, tachycardia, and sometimes at the beginning with
dysphagia, cough, hoarseness due to frequently severe
compression of the lungs, bronchus and recurrent nerve.
The manifestation of shock is finally dominant.
Physical examination determines the typical signs of tamponade:
1. systemic hypotension (low stroke and minute volume);
2. jugular vein distension as a sign of a failure of filling RV
and rise in pressure in the right side of the heart and venous
system,
3. a muffled or inaudible heart sounds (with tachycardia) —
all called as characteristic Beck’s triad14.
Tachycardia is almost always present due to compensatory
sympathicotonia and catecholamine, in response to the fall
in stroke volume and history of trauma: tachypnea (compression of the lungs, bronchi, hypoxia), paleness of skin
and mucous membranes, and potential peripheral cyanosis.
Pericardial friction is not heard in major effusion. Larger hemopericardium compresses the left pulmonary lobe, which
is reflected by dullness to percussion and inaudible breathing auscultatory (Ewart’s sign). Otherwise, there are no
physical signs of delays in the lungs which is a typical phenomenon. Arterial pressure is low — around or below 90
mmHg. When venous pressure in cubital vein was measured, it would be elevated.
A typical Kussmaul’s sign may be present. It is reflected by
reducing neck vein distension in inspiration (which is not
expressed as more severe hypovolemia) and characteristic
paradoxical pulse finding, accompanied by a potential pressure drop. Paradoxical pulse is a slowdown of the heart rate
in the inspiration (acceleration is normal), which is difficult to
assess clinically in presence of tachypnea. Blood pressure
measured in the inspiration should also drop to 15-20 mmHg
in order to accept the sign as positive for tamponade (which
is classified as paradox by some clinicians). The drop in
pressure in the inspiration is otherwise normally present in
healthy individuals, but also in other diseases, so sensu stricto this drop can not be called a highly specific paradoxical
sign.
Reduction of jugular vein distension in the inspiration is a
sign of a short-term drop in pressure in RA and intrapericardially as a result of a negative pressure in the chest. This allows only a slow filling of RV and transitory increase in cavity size of RV in the inspiration.
For pericardial tamponade and injury there is no pathognomonic ECG sign, but sometimes several significant ones
can be determined: 1. elevation of the ST-segment at the
top typically concave; 2. electrical alternans; 3. low voltage
of amplitude of QRS-complex (the sum of the amplitudes in
D1, D2, D3 less than 15 mm). The latter is also an insensitive and a nonspecific sign of the so-called “short circuit” in
the electrical impulse travel through the pericardial effusion,
2013;8(10-11):336.
postoji i u pretilosti, u pleuralnom izljevu lijevo, nekim kardiomiopatijama, amiloidozi...)15,16.
Jak porast intraperikardijskog tlaka u tamponadi oπteÊuje i
smanjuje protok u subendokardnom i subepikardnom dijelu
miokarda uzrokujuÊi time miokardnu ishemiju, koja se moæe
oËitovati u zapisu 12-kanalnog EKG-a kao konveksna elevacija ST-spojnice s pozitivnim ili negativnim T-valom.
Depresija ST-spojnice je iznimna. Opisani nalaz ST-spojnice na EKG-u u tamponadi je takoer nespecifiËan. Vrlo su
rijetki q- ili QS-zupci i takoer nisu izraz perikardnog oπteÊenja u tamponadi, nego subepikardnog oπteÊenja miokarda, jer i elektrofizioloπki visceralni i parijetalni list perikarda i
inaËe normalno ne stvaraju nikakvu razliku elektriËnog potencijala zbog male mase perikarda, da bi je se moglo uopÊe
registrirati15. Ruptura miokarda uz tamponadu, ovisno o
veliËini, moæe dati sliku nekroze s q- ili QS-zupcima. Razumljivo je, stoga, da i laboratorijski nalazi specifiËnih miokardnih enzima i troponina ukazuju samo na dodatno oπteÊenje
miokarda, a ne perikarda5,15.
Prilikom ehokardiografskog pregleda u tamponadi mogu se
utvrditi sljedeÊi znakovi:
1. poveÊanje DV u inspiriju s reciproËnim smanjenjem LV;
2. kolaps DA u ekspiriju;
3. kolaps DA u sistoli duæe od treÊine trajanja sistole (osjetljivost 90%, specifiËnost 100%);
4. dijastoliËki kolaps DA i ev. LA, a vrlo rijetko LV;
5. paradoksni pomak iv. septuma u inspiriju prema LV;
6. kolaps DV neposredno nakon zatvaranja pulmonalnog
zalistka i otvaranja trikuspidnog, dakle, u ranoj dijastoli;
7. suæenje — kolaps izgonskog trakta DV, eksperimentalno
osjetljiviji znak Ëak od kolapsa DV
8. distenzija — dilatacija vene kave inferior (subkostalnim
pristupom) bez smanjenja za 50% u inspiriju (πto upuÊuje na
poveÊani srednji tlak u DA iznad 10 mmHg);
9. poveÊanje protoka u inspiriju, mjereno Doppler metodom,
kroz trikuspidno uπÊe, a smanjenje protoka u inspiriju kroz
mitralno uπÊe i obratno u ekspiriju
10. pristupom transtorakalno-supraklavikulano (iz juguluma)
moæe se utvrditi stanje arkusa aorte, asc. aorte i proksimalnog dijela desc. aorte te s izvjesnom sigurnoπÊu dokazati ili
iskljuËiti disekciju aortne stijenke kao moguÊi uzrok tamponade17.
as it is even present in obesity in the left pleural effusion,
some cardiomyopathies, amyloidosis ... )15,16.
A strong elevation of intrapericardial pressure in the tamponade damages and reduces the flow in the subendocardial
and subepicardial part of the myocardium causing thus the
myocardial ischemia, which can be manifested in a record of
12-lead ECG as convex elevation of the ST-segment with
the positive or negative T-wave. The depression of the STsegment is exceptional. The described finding of the STsegment on ECG in the tamponade is also nonspecific. Q or
QS waves are very rare and are also not the sign of the pericardial tamponade, but of subendocardial myocardial injury,
because the electrophysiological visceral and parietal layer
of the pericardium normally make no difference in the electric potential due to a small pericardial mass, so that it could
be recorded at all15. Myocardial rupture with tamponade, depending on size, can give an image of necrosis with Q-or
QS-wave. It is understandable, therefore, that laboratory findings of specific myocardial enzymes and troponin just additionally indicate the injury of the myocardium, not of pericardium5,15.
When making echocardiographic examination of tamponade
the following signs can be determined:
1. elevation of RV in the inspiration with reciprocal reduction
in LV;
2. collapse of RA in the expiration;
3. RA collapse in systole longer than a third of the systole
duration (sensitivity 90%, specificity 100%);
4. diastolic collapse of RA and potentially LA, very rarely LV;
5. paradoxal shift of iv. septum in the inspiration towards LV;
6. collapse of RV immediately after the closure of pulmonary
valve and opening of tricuspid valve, that is, in early diastole;
7. constriction — RV outflow tract collapse, experimentally a
sign even more sensitive than the RV collapse
8. distension — inferior vena cava dilatation (by subcostal approach) without reduction by 50% in the inspiration (which indicates an elevated medial pressure in RA above 10 mmHg);
9. an increase in the flow in the inspiration, measured by
Doppler method, through the tricuspid orifice, and a decrease in flow in the inspiration through the mitral orifice and
reversely in the expiration
10. by transthoracic-supraclavicular approach (from the jugulum) we can determine the condition of aortic arch, ascending aorta and proximal part of descending aorta and can
with a certainty prove or exclude the dissection of aortic wall
as a possible cause of tamponade17.
Patomorfologija i kliniËka slika kontuzije
miokarda
Pathomorfology and clinical course of
myocardial contusion
Kontuzija miokarda (nagnjeËenje od udarca) je u veÊini sluËajeva ekvivalent tupe, nepenetrantne traume srca povezane s tupom traumom prsnog koπa (ponekad i tupom traumom trbuha)1,4,8. Ova trauma srca ovisi o snazi “tupih” sila u
djelovanju na prsni koπ, ponajprije o uËinku tzv. akceleracijskih sila koje djeluju ne samo na povrπinu prsnog koπa,
nego time i na povrπinu srca te na povrπinu i unutraπnjih
srËanih struktura i drugih organa u prsnom koπu. UËinak
ovisi o mjestu udara, rasteæljivosti prsnog koπa (djeËji ima
poveÊanu rasteæljivost, pa je manje smrtnih sluËajeva u prometu) i o fazi srËane rezolucije u kojoj se dogodio udarac.
Dokazano je na animalnim modelima da nekad i manja sila
u kritiËnoj fazi srËane rezolucije moæe izazvati naglu smrt15,18.
Nema danas standardnih parametara za toËnu procjenu
veliËine, jaËine sile i snage tupe traume kod ljudi koja dovodi do kontuzijskog oπteÊenja, πto je razumljivo. KritiËnu fazu
srËane rezolucije kod ljudi takoer je gotovo nemoguÊe
Myocardial contusion (contusion caused by a blow) is in
most cases equivalent to blunt, non-penetrating cardiac
trauma associated with blunt chest trauma (sometimes even
by blunt abdominal trauma)1,4,8. The cardiac trauma depends
on the strength of “blunt” forces exerted on the chest, primarily on the effect of the so-called acceleration forces exerted
not only on the surface of the chest, but consequently also
on the surface of the heart and on the surface of internal cardiac structures and other organs in the chest. The effect depends on the site of impact, compliance of the chest (children’s chest has increased compliance, so there is fewer
number of fatalities in car accidents) and the stage of cardiac resolution in which the impact occurred. It has been
proved on animal models that sometimes less force at a critical stage of the cardiac resolution can cause a sudden
death15,18. Today there are no standard parameters for an accurate assessment of the size, strength of force and power
of blunt trauma in people that leads to contusion, which is
understandable. The critical stage of the cardiac resolution
2013;8(10-11):337.
Cardiologia CROATICA
odrediti, jer nitko ne nosi holter EKG-aparat u fazi doæivljene
sile. Ostaje kao jedina toËnija procjena snage sile tupe miokardne traume prema histoloπkom nalazu na autopsiji.
Patomorfoloπke promjene mogu se histoloπki utvrditi u obliku blagog edema tkiva miokarda, intramuralne hemoragije,
manje ili veÊe nekroze miokarda koju moæe slijediti ruptura
stijenke1,4,6,14. Ruptura miokarda kod tupe traume srca javlja
se u oko 0,3%-1,1% (neposredno) traumatiziranih. U duljem
promatranju posttraumatskog stanja, nekad i mjesecima ili
godinama, dogaaju se i smrtni ishodi. Mislimo da je teπko
dokazati uzroËnu povezanost nakon duæeg vremena od
traume pa je moguÊe da u studijama (koje navode visoku
posthospitalnu smrtnost) nisu dovoljno iskljuËeni svi drugi
uzroËni faktori?
Pneumoperikard se moæe javiti poslije tupe traume, komplicirane rupturom, laceracijom perikarda i okolnog pluÊnog
tkiva (dokazuje se MSCT pretragom prsnog koπa). OπteÊenja koronarnih arterija u tupoj se traumi dogaaju u oko 2%
i to najËeπÊe lijeva prednja silazna aterija, ali i desna koronarna arterija koja je lacerirana desno iza sternuma, dok je
cirkumfleksna arterija zahvaÊena vrlo rijetko19-21. Viπeæilna
koronarna oπteÊenja su rijetka. Traumatska valvularna disfunkcija s nastankom pluÊnog edema je takoer rjea6.
NajËeπÊe je oπteÊena aortna valvula, slijede mitralna i trikuspidna. Mehanizam nastanka disrupcija kuspisa je nagli porast intrakardijalnog tlaka kod zatvaranja valvule. Uzroci
valvularne disfunkcije su rastrgnuÊe ili izvrnuÊe, otrgnuÊe
(avulzija) anulusa i najËeπÊe nekoronarnog aortnog kuspisa6.
VeÊ sam edem miokarda moæe kompromitirati koronarnu
cirkulaciju kompresijom pa se razvije (“sekundarna”) ishemija4,18. S obzirom da se proces djelovanja tupe sile dogaa
preteæno u miokardu, razumljivo je da se elektrokardiografski moæe manifestirati kao ishemija ili ËeπÊe kao infarkt miokarda, koji ima ponekad i zupce nekroze q- ili QS. ST-spojnica u takvim oπteÊenjima obiËno je elevirana s konveksitetom na vrhu (kao u infarkta), a T-valovi ËeπÊe su odmah negativni. ST-spojnica moæe u nekim odvodima biti i jaËe denivelirana. Vaæno je istaknuti da neposredno uËinjen EKG s
patoloπkim promjenama identificira riziËnog bolesnika, ali
normalan nalaz EKG-a neposredno nakon incidenta nije od
pomoÊi, jer mu je vrijednost negativno prediktivna. Neposredno nakon incidenta, ako je kontuzijska sila bila jaka
mogu se utvrditi uËestale srËane aritmije u oko 28% tupih
ozljeda8 uz smetnje provoenja. ObiËno se radi o neopasnim
ekstrasistolama, supraventrikulskim tahikardijama, atrijskim
ekstrasistolama. »est je blok desne grane koji u lakπoj ozljedi i nestaje unutar 24 sata, a blok lijeve grane je rijedak.
Javljaju se i ventrikulske ekstrasistole i ventrikulska tahikardija, sliËno kao u ranom postinfarktnom razdoblju, koja kod
manjih oπteÊenja dobro reagira na medikamentnu terapiju
(amiodaronom, a rijetko je potrebno dati alternativni lijek —
lidokain 100 + 50 mg).
Meutim, ne smije biti iznenaenja za ekipu HMP jer se u
ranom razdoblju poslije teπke kontuzije javlja i postojana
ventrikulska tahikardija (bez pulsa) pa i fibrilacija ventrikula
(ritmovi koji se defibriliraju), a koji se javljaju uz srËani arest
te se trebaju intenzivno lijeËiti prema novim smjernicama22,23.
Nakon tri poËetne defibrilacije bez uspjeha, preporuËa se
ordinirati adrenalin 1 mg i.v. (ili intraosealno: humerus, tibia)
i ponavljati ga svakih 3-5 minuta. Javlja li se ponovljeno fibrilacija ventrikula treba ordinirati amiodaron 300 mg i.v. u 5%
glukozi u bolusu te ev. dodatno joπ 150 mg amiodarona.
»esto se ipak dogodi neuspjeh te se javlja asistolija — stanje bez elektriËne ventrikulske aktivnosti, iako elektriËna akCardiologia CROATICA
in people is also almost impossible to determine because no
one wears Holter ECG monitor in the stage of experienced
force. The only accurate assessment of strength of myocardial blunt force trauma force can be made according to the
histological findings at autopsy.
Pathomorphological changes can be histologically determined in the form of mild edema of the myocardial tissue, intramural hemorrhage, minor or major myocardial necrosis, which
may be followed by rupture of the wall1,4,6,14. Myocardial rupture in blunt cardiac trauma occurs in approximately 0.3% 1.1% of (directly) traumatized persons. Deadly outcomes
occur in a longer observation of post-traumatic condition, sometimes lasting for months or years. We think it is difficult to
prove a causal connection after a long time since the period
of trauma, so it is possible that studies (indicating a high
post-hospital mortality) do not sufficiently exclude all other
causal factors.
Pneumopericardium may occur after the blunt trauma, being
complicated by rupture, laceration of the pericardium and
surrounding lung tissue (as proved by MSCT examination of
the chest). Damage to the coronary arteries in blunt trauma
occurs in about 2%, mostly it is the left anterior descending
artery and the right coronary artery which is lacerated on the
right side behind the sternum, while the circumflex artery is
rarely affected19-21. Multi-vessel coronary injuries are rare.
Traumatic valvular dysfunction with the development of pulmonary edema is also more rare6. Aortic valve, followed by
mitral and tricuspid valve are mostly damaged. The mechanism of development of cusp disruptions is a sudden elevation of intracardial pressure when closing the valve. The
causes of valvular dysfunction are tear or distortion, avulsion
of annulus and usually of non-coronary aortic cusp6.
The myocardial edema itself may compromise the coronary
circulation by compression resulting in the development of
(“secondary”) ischemia4,18. Since the process of exerting
blunt force mainly occurs in the myocardium, it is understandable that it can be manifested as ischemia by electrocardiographic leads, or more often as myocardial infarction,
whereas q or QS waves sometimes suggest necrosis. The
ST-segment in such injuries is usually elevated with the convexity on the top (as in the infarction), and T-waves are often
immediately negative. The ST-segment may in some leads
be even more denivelated. It is important to point out that
recently performed ECG with pathological changes identify
a patient at risk, but the normal finding of ECG taken immediately after the incident is of no help, because its value is
negatively predictable. Immediately after the incident, if the
contusion force was strong, frequent cardiac arrhythmias in
around 28% of blunt injuries8 with the conduction disturbance can be determined. Usually, these are harmless extrasystoles, supraventricular tachycardia, atrial estrasystoles that are concerned. The right bundle branch block which
in case of minor injury disappears within 24 hours, while the
left bundle branch block is rare. Ventricular extrasystoles
and ventricular tachycardia also occur, similar to the early
postinfarction period, which in case of minor injuries are well
treated by medicamentous therapy (amiodarone, and an
alternative medicine — lidocaine 100 + 50 mg is rarely to be
administered).
However, the EMS team should be not surprised, because
the early period after the severe contusion is followed by the
sustained ventricular tachycardia (pulseless), including ventricular fibrillation (rhythms that are defibrillated), which occur along with cardiac arrest and they should be treated intensively according to the new guidelines22,23. After three initial defibrillations without success, it is recommended to prescribe epinephrine 1 mg i.v. (or intraoseal: humerus, tibia)
which is to be repeated every 3-5 minutes. If the ventricular
fibrillation reoccurs, amiodarone 300 mg i.v. in 5% glucose
in bolus and additionally 150 mg amiodarone should be prescribed.
2013;8(10-11):338.
tivnost moæe postojati u vidu P-valova koji nisu uvijek vidljivi
na EKG-u. Potrebno je ponovno procjeniti spoj elektroda i
ocijeniti nalaz EKG-a. Moæe postojati asistolija i kod sumnje
da se radi pretpostavljeno o tzv. “finoj fibrilaciji ventrikula”
(nevidljivoj u EKG zapisu) te se donedavno i u toj situaciji
nastavljalo s defibrilacijom. Danaπnji je stav da se kod asistolije sumnjive na “finu” fibrilaciju ventrikula ne Ëini ponovo
defibrilacija?! Ritmovi koji se ne defibriliraju su dokazana
(agonalna) prava asistolija i elektriËna aktivnost bez pulsa
(PEA), Ëesto zvana elektromehaniËka disocijacija. Kod asistolije ili razvoja bloka moæe se pokuπati s perkutanom stimulacijom, primjenom torakalnih elektroda ili dakako aplikacijom sa spomenutim adrenalinom. Nove preporuke smatraju
da primjena atropina od 3 mg u bolusu nije od velikog uËinka (iako ga i nadalje primjenjujemo u pojedinim situacijama
kao potentnog vagolitika).
Prema novim stavovima Europskog druπtva za resuscitaciju22,23, objavljenim 2010. godine, preæivljavanje nakon kardijalnog aresta s asistolijom ili elektriËnom aktivnosti bez pulsa
je malo vjerojatno, ako se odmah ne otkriju i ne rijeπe uzroci (kao πto je to ovdje tamponada perikarda). Kod prave asistolije nema koristi od elektriËne stimulacije konsensus je
struËnjaka na internacionalnoj razini.
U kontuzijskim oπteÊenjima srca nisu se smatrale potrebnim
druge hospitalne mjere, poput privremenog uvoenja hipotermije 32-34°C, ako bolesnik poslije kardijalnog aresta srca
nije bio u komi i nema neuroloπke ispade. Sadaπnja preporuka je da se stanje poslije kardijalnog aresta tretira i hipotermijom. Vrlo je rijetko potrebna mehaniËka ventilacija uz
miorelaksanse i sedaciju, a ekstremno rijetko primjena danas moderne mehaniËke potpore srËanoæilnom sustavu
aparaturom VAD, BIVAD, LVAD, RVAD, LVAS — HEART
MTTE II ili dr.
Sva simptomatologija i kliniËki status ovise o veliËini oπteÊene miokardne mase, koja Êe dovesti do asistolije i nepopravljivog kardijalnog aresta. Uniπtenje >50% miokardne mase
je vrlo riziËno24. U kontuzijama prsnog koπa viπe je izvrgnut
oπteÊenju DV, a masa njegova miokarda je manja od mase
LV, pa i porast miokradnih specifiËnih enzima i troponina,
usprkos jakoj sili moæe stoga biti blag πto ne pridonosi ocjeni
teæine kliniËke slike5.
Tupa trauma prsnog koπa s kontuzijom miokarda je statistiËki ËeπÊa od penetrantne ozljede, ali Ëini se da je neposredno za æivot manje opasna. »esto se postavlja pitanje nagle
smrti sportaπa koji su doæivjeli mnoge manje ili veÊe tupe
traume prsnog koπa, npr. nogometaπa (padovi, sudari, udarci loptom u prsa i sl.), a koji su praktiËki svi bili prije kardioloπki pregledani i nisu imali dokazane uobiËajene uzroke
nagle srËane smrti. Malobrojno snimani EKG kod kolapsa,
odnosno sinkopa nogometaπa na terenu ipak ukazuju na
malignu ventrikulsku tahikardiju, moæda vezanu uz ranije
tupe traume? Ako se poslije tupe traume prsnog koπa razvije rezistentna hipotenzija usprkos adekvatnoj resuscitaciji
hipovolemije i ako nije prisutan drugi evidentni uzrok stanja,
treba napraviti dodatnu koronarografiju21.
However, a failure often occurs, whereas asystole occurs —
the state without electrical ventricular activities, although
electrical activity may exist in the form of P-waves which are
not always visible in the ECG. It is necessary to re-evaluate
the connection of electrodes and evaluate the ECG findings.
Asystole may exist when suspecting that the so called “fine
ventricular fibrillation” (invisible in the ECG record) is concerned and until recently defibrillation continued to be performed in this situation. The today’s attitude is that no repeated defibrillation should be performed in case of asystole
susceptible for the “fine” ventricular fibrillation. Rhythms that
are not defibrillated are proven (agonal) asystole and pulseless electrical activity (PEA), often called electromechanical
dissociation. In asystole or development of the block, one
can try with percutaneous stimulation, by applying the thoracic electrodes or by administering the above mentioned
adrenaline. The new recommendations suggest that the
administration of 3 mg atropine in bolus is of a little effect
(although we still apply it in certain situations as a potent vagolytic).
According to the new guidelines of the European Resuscitation Council22,23, published in 2010, the survival after cardiac arrest with asystole or pulseless electrical activity is
less likely if causes are not immediately detected and resolved (as it is pericardial tamponade here). In case of a true
asystole there is no use of electrical stimulation, which is a
consensus of experts at an international level.
In contusion-related cardiac injuries no other in-hospital measures, such as the temporary introduction of hypothermia
32-34°C were considered necessary, if a patient was not in
a coma and had no neurological disorders after the cardiac
arrest. The current recommendation is that the condition after the cardiac arrest is treated by hypothermia. Mechanical
ventilation with myorelaxants and sedation is very rarely required, and the today modern mechanical support to cardiovascular system by apparatus VAD, BIVAD, LVAD, RVAD,
LVAS — HEART MTTE II etc. is extremely rarely used.
All the symptoms and clinical status depend on the size of
the injured myocardial mass, which will lead to asystole and
irreparable cardiac arrest. The destruction of >50% of myocardial mass is very risky24. RV is more exposed to injuries
in case of chest contusions, while its myocardial mass is lower than that of the LV, so the increase in myocardial specific enzymes and troponins, despite a strong force can therefore be slight which does not contribute to the assessment
of severity of clinical course of the disease5.
Blunt chest trauma with myocardial contusion is statistically
more common than penetrating injury, but it seems to be directly less dangerous to life. A frequently asked question is
posed in connection with a sudden death of athletes who have experienced many minor or major blunt chest traumas,
for instance football players (falls, collisions, blow to the
chest by a ball, etc.), who previously underwent cardiac examinations and had no proven common causes of sudden
cardiac death. A small number of taken ECGs in case of collapse or syncopes sustained by the players on the playground indicate a malignant ventricular tachycardia, which
may be related to the earlier blunt trauma? If the blunt chest
trauma is followed by the development of resistant hypotension despite an adequate resuscitation of hypovolemia, and
if no other obvious cause of the condition is present, an
additional coronary angiography should be performed21.
Ostale hitne intervencije kod traume srca
Other emergency interventions in cardiac trauma
Dijagnozu traume srca, osobito penetrantne, trebalo bi utvrditi πto prije poslije doæivjelog incidenta, jer hitna intervencija kod sumnje na razvitak tamponade perikarda moæe spasiti æivot unesreÊenika i uvjet je za uspjeπnu reanimaciju,
ako se dogodi kardijalni arest. OËevidna rana, razderotina
The diagnosis of the cardiac trauma, particularly penetrating
cardiac trauma, should be made as soon as possible after
the sustained incident, because the emergency intervention
when suspecting the development of pericardial tamponade
may save the life of the injured and is the prerequisite for
successful resuscitation if cardiac arrest occurs. The appar-
2013;8(10-11):339.
Cardiologia CROATICA
na prsnom koπu, veÊ inspekcijom upuÊuje na vrlo vjerojatnu
i razderotinu, ranu srca. Ako se radi o ozljedi vatrenim projektilom potrebno je utvrditi i izlaznu ranu, kako bi se mogao
predvidjeti put projektila i oπteÊenje drugih organa na tom
putu te ocijeniti zadræavanje projektila u nekom od organa.
Pogodak u samo rebro ili sternum projektilom ili noæem
dovodi do rasprsnuÊa koπtanih struktura te upuÊuje i na laceraciju srca. Procjena stanja pacijenta s takvom ozljedom
mora se, dakako, temeljiti na uobiËajenom planu zbrinjavanja i algoritmu pristupa za akutne hitne incidente, koji traæi reanimaciju oznaËenu akronimom ABCDE — Airway, Breathing, Circulation, Defibrillation odnosno Disability, Expose
(osloboditi diπne puteve, procijeniti disanje, primijeniti umjetno disanje, dok se primjena ruËne masaæe preko donjeg
dijela sternuma kod sumnje na tamponadu dakako ne savjetuje, nego dolazi u obzir procjena pulsa, tlaka, cirkulacije,
a defibrilaciju u sluËaju ventrikulske tahikardije i fibrilacije
treba uËiniti odmah, ako nema reakcije na medikamentnu
terapiju primijenjenu i.v. ili intraosealno6,22,23. Viπe se ne preporuËa davanje lijekova intratrahealno zbog slabe resorpcije.
Ljestvica traumatskih oπteÊenja prsnog koπa i srca ima πest
stupnjeva i detaljno je opisana u literaturi24.
Ishod penetrantne i nepenetrantne ozljede ovisi od tri Ëimbenika: 1. brzina pruæanja pomoÊi na mjestu incidenta; 2.
struËnost i opremljenost ekipe HMP; 3. brzina transporta uz
neophodno obavjeπtavanje ekipe u kirurπkom centru za primitak i intervenciju traumatiziranog1,5,12,13,18-21,25.
Stanje unesreÊenog s penetrantnom ozljedom srca na mjestu nesreÊe u dijagnostiËkom je pogledu sloæeno. Moæe biti
veÊ prisutan kardiogeni πok s distendiranim jugularnim
venama ili /i hipovolemiËki πok (kada je ta distenzija slabije
izraæena), a πto sve upuÊuje na brzi razvoj smrtne tamponade perikarda kod vidljive rane na prsnom koπu.
OπteÊenje projektilom velikog kalibra iz vatrenog oruæja ili
πiroke ubodne rane dovode u veÊini incidenata do trenutne
smrti, dok oπteÊenje projektilom malog kalibra i ubodne rane
oπtrim, uskim predmetom (frakturirano rebro, dio — iversternuma, vrh noæa) mogu se lijeËiti i sprijeËiti tamponadu.
Kod malog projektila, ulazna rana ne mora biti vidljiva na
prvi pogled, jer se kao mala ekhimoza izmeu dva rebra,
lako previdi. Upravo takve male, “nevidljive” ulazne rane mogu imati kobne posljedice. EKG zapis u toj situaciji s nastalom tamponadom, daje gotovo uvijek, pa i u malom penetrantnom oπteÊenju miokarda, sliku perakutne lezije ili ishemije miokarda s eleviranom ST-spojnicom, najËeπÊe konkavnom na samom vrhu elevacije — upravo sliËno nalazu u
prvim satima perakutnog infarkta miokarda, koji inaËe rijetko
viamo (jer se veÊ u akutnoj fazi infarkta nalazi samo konveksna ST-elevacija). Konkavnost na vrhu elevirane STspojnice je suprotna glavnoj el. osi T-vala, koji u poËetku te
male ozljede moæe biti i pozitivan26. Slijedi inverzija T-vala te
se takav bolesnik obiËno smjeπta u intenzivnu skrb i najËeπÊe lijeËi kao infarkt miokarda. Manja disrupcija miokarda
od manjeg projektila moæe privremeno, spontano trombozirati. Meutim, na temelju krivo postavljene dijagnoze infarkta bolesniku zapoËinje se lijeËenje koje dovodi (ovdje s pravom kaæemo naæalost) do trombolize veÊ stvorenog tromba
na mjestu razderotine i daljnji razvoj tamponade srca te
bolesnik umire u intenzivnoj skrbi neutvrene dijagnoze.
Stoga za toËnu procjenu stanja prijeteÊe tamponade srca,
kod penetrantne i nepenetrantne ozljede prsnog koπa, lijeËnik HMP (prema europskim preporukama za reanimaciju) na
mjestu incidenta mora imati pri ruci prenosivi ehokardiografski aparat te se njime odmah orijentirati (kao πto Ëini EKGCardiologia CROATICA
ent wound, chest laceration is a sign for a very probable tear
and cardiac injury as determined by the examination. In the
case of an injury caused by fire missile, it is necessary to
determine the entry and exit wound, in order to be able to
predict the path of missile and injury of other organs in this
path, and assess the retention of the missile in some of the
organs. A blow to the rib only or sternum by a missile or a
knife leads to bursting of bone structure indicating thus the
cardiac laceration. The assessment of the patient’s condition with such an injury must, naturally, be based on the
usual management plan and algorithm for acute emergency
incidents, requiring resuscitation indicated as acronym ABCDE — Airway, Breathing, Circulation, Defibrillation and Disability Expose (free airways, assess breathing, apply artificial respiration, while the use of manual massage over the
lower part of the sternum when suspecting tamponade is
certainly not advised. However, the evaluation of pulse,
blood pressure and circulation will be taken into consideration, while defibrillation is to be performed immediately in case of ventricular tachycardia and fibrillation, if there is no response to medicamentous therapy administered i.v. or intraosseously6,22,23. Administration of medicines intratracheally is no longer advisable due to poor absorption.
The scale of traumatic injuries of the chest and heart has six
degrees and it is described in the literature24.
The outcome of penetrating and non-penetrating injury depends on the three factors: 1. promptness in providing assistance on the spot of the incident; 2. expertise and equipment
of EMS team; 3. the speed of transport accompanied by providing information to the surgical center about the necessity
to admit and manage the traumatized person1,5,12,13,18-21,25.
The condition of the injured with a penetrative cardiac injury
on the spot of an incident is complex in terms of diagnostics.
Cardiogenic shock with distended jugular veins and/or hypovolemic shock (when this distension is slightly pronounced)
may be present, indicating the rapid development of fatal
pericardial tamponade in visible chest wounds.
Damage caused by a large caliber missile from firearms or
a wide stab wound in most incidents result in the immediate
death, while the damage caused by a small caliber missile
and stab wounds caused by a sharp, narrow object (fractured rib, part — body of sternum, tip of a knife) can be treated with prevention of tamponade. In a case of a small missile, the entry wound may not be apparent at a first glance,
because it is easily overlooked as a small ecchymosis between the two ribs. Such small, “invisible” entry wounds can
have fatal consequences. ECG recording in this situation
with the developed tamponade gives almost always, even in
a minor penetrative myocardial injury, an image of percutaneous lesion or myocardial ischemia with ST-segment elevation, usually concave at the top of the elevation — similar
to a finding in the first hours of percutaneuous myocardial infarction, which we otherwise can rarely see (because already in the acute phase of myocardial infarction we can only
see a convex ST-elevation). The concavity at the top of the
ST-segment elevation is opposite to the main el. axis of the
T-wave, which in case of a minor injury can initially be even
positive26. It is followed by T-wave inversion, and such a patient is usually referred to the intensive care unit and is often
treated as myocardial infarction. Minor myocardial disruption
caused by a small missile can be temporarily spontaneously thrombosed. However, should the faulty diagnosis of infarction in the patient be made, the treatment will begin (here
we are right to say unfortunately) resulting in a thrombolysis
of the already created thrombus at the site of laceration and
further development of cardiac tamponade, and the patient
dies in the intensive care unit with undetermined diagnosis.
Therefore, for accurate assessment of the condition of lifethreatening cardiac tamponade, in case of penetrating and
non-penetrating chest trauma, the EMS physician (according to the European guidelines on resuscitation) must at the
spot of the incident have portable echocardiography device
2013;8(10-11):340.
om o ritmu i frekvenciji srca) o stanju, koliËini perikardijskog
sadræaja, ali ev. i o laceraciji miokarda, perikarda te stanju
srËanih πupljina. Potom slijedi eventualno i terapijski postupak da se pokuπa takvog bolesnika s prijeteÊom ili veÊ izraæenom tamponadom perikarda spasiti terapijskom perikardiocentezom koja nije samo zahvat za kardiologa i kardiokirurga nego je u ovim iznimnim sluËajevima struËni zadatak
za koji treba biti osposobljen lijeËnik HMP, uz pomoÊ i asistiranje medicinske sestre ili tehniËara.
Medicinska doktrina kaæe: “osim u hitnim sluËajevima —
tamponade perikarda, terapijsku perikardiocentezu, koja je
potencijalno i opasna, treba uËiniti pod kontrolom ultrazvuka
srca u prostoriji za kateterizaciju srca.” Na mjestu incidenta
nema sobe za kateterizaciju, to moæe biti doduπe dobro
opremljeno, adaptirano vozilo HMP, ali je praktiËnije, bræe,
uËinkovitije terapijsku perikardiocentezu uËiniti neposredno
uz leæeÊeg bolesnika vani, πto je dopuπteno citiranom doktrinom (i opisano kao uspjeπno). Ako lijeËnik HMP utvrdi
perikardijski sadræaj koji oblaæe miokard iza LV i ispred DV
s fenomenom “lelujajuÊeg” srca (“swinging heart” — srca
koje se impresivno klati), a πto je u akutnim sluËajevima izraz velikog izljeva koji aproksimativno prelazi 1.500 mL, uz
pomoÊ asistenta, koja dræi glavu sonde ultrazvuka i “osvjetljava” srce, lijeËnik bi trebao duæom iglom i veÊom πtrcaljkom
100-200 mL, uËiniti punkciju perikarda, pristupom iz subksifoidnog podruËja, subkostalno lijevo, s usmjerenjem punkcijske igle prema gore i lijevom ramenu, pod kutom od 30
stupnjeva. Poæeljno je da se bolesnika postavi u polusjedeÊi
poloæaj ili u leæeÊi na desnom boku. Taj zahvat s aspiracijon
i 100 mL perikardijskog sadræaja spaπava æivot unesreÊenog
i omoguÊuje “kupovanje vremena” za transport do kirurπkog
centra. Evakuacija i samo 50 mL veÊ dovodi ponekad do
olakπanja i Ëesto zaustavlja razvoj tamponade.
Drugi problem, koji zavrπava smrtno u danim okolnostima je
nastup asistolije kada (pored moguÊnosti perkutane stimulacije) u veÊoj udaljenosti od kirurπkih centara treba dati
prednost, uvoenju privremenog elektriËnog stimulatora
srca preko centralnog venskog sustava gornje πuplje vene,
vene subklavije ili unutarnje jugularne, vene cefalike. Zahvat
treba uËiniti takoer odmah uz leæeÊeg pacijenta, bez radioloπke pomoÊi (koja se zbog hitnosti uz dobro iskustvo lijeËnika ne koristi uvijek ni u jedinicama intenzivne skrbi). Implantacija centralnog venskog katetera istim pristupom daje
ujedno informaciju o visini centralnog venskog tlaka u πupljinama desnog srca, o ev. hipovolemiji πto usmjeruje i odreuje daljnju terapiju27. Istim venskim pristupom, u vrijeme hospitalizacije u intenzivnoj skrbi, moæe se implantirati i Swan
Ganzov kateter te ga plasirati preko trikuspidnog uπÊa u
pluÊnu arteriju, s kratkotrajnom opstrukcijom arterije da se
izmjeri visina pluÊnog kapilarnog tlaka koji je jednak tlaku u
LA (normalno do 10 mmHg). Time se ujedno dobije procjena stanja miokarda LV, teledijastoliËkog tlaka u LV kao izraz
teledijastoliËkog volumena i kontraktilnosti. Kod tog zahvata
postoji moguÊnost oπteÊenja trikuspidnog zalistka te zadnje
vrijeme postoje kontroverze o tome poboljπava li preæivljavanje.
Ovdje je iznesen moderan pristup tretmanu prijeteÊe tamponade srca, koji se sprovodi u razvijenim europskim zemljama i traæi struËnost i materijalno ulaganje u opremljenost
HMP.
2013;8(10-11):341.
on him as to immediately define (as rhythm and heart rate
are determined by the ECG) the condition, quantity of pericardial fluid and any myocardial or pericardial lacerations
and condition of the heart cavities. This may be followed by
therapeutic procedure attempting to save such a patient with
life-threatening or already pronounced pericardial tamponade by performing therapeutic pericardiocentesis which is
not only an intervention to be performed by a cardiologist
and cardiac surgeon, but in these exceptional cases, this is
the task that is to be performed by a qualified EMS physician, with the help and assistance of a nurse.
Medical doctrine says, “except in emergency cases — pericardial tamponade, therapeutic pericardiocentesis, which
may be dangerous, should be done under heart ultrasound
in a room for a heart catheterization.” On the spot of the incident there is no room for catheterization, but this may be a
well equipped, adjusted EMS vehicle anyway, although it is
more convenient, faster, more effective to perform therapeutic pericardiocentesis directly next to the lying patient outside, as permitted by the quoted doctrine (and described as
successful). If the EMS physician determines pericardial
content coating the myocardium behind the LV and in front
of the RV with the phenomenon of “swinging heart” — the
heart which impressively swings), which is in acute cases
the expression of a large effusion that approximately exceeds 1.500 mL, the physician should with the help of an
assistant who keeps the head of the ultrasound probe and
“illuminates” the heart, use a longer needle and syringe of
100-200 mL to do the pericardial puncture via the left subxiphoid subcostal region, directing the punctuation needle upwards and left shoulder, at an angle of 30 degrees. It is desirable to place the patient in a semi-sitting position or lying
on the right side. This procedure with aspiration and 100 mL
of pericardial content will save the life of the injured and
allows “buying time” for transportation to the surgical center.
The evacuation and only 50 mL, already results in relief and
often stops the development of the tamponade.
The second problem resulting in fatal outcome in the given
circumstances is the development of asystole when (in addition to a possibility of percutaneous stimulation) at a greater
distance from the surgical centers the priority should be given to the introduction of temporary electrical pacemaker via
a central venous system of superior vena cava, subclavian
vein or internal jugular, cephalic vein. The procedure should
be also done immediately with the lying patient, without radiological assistance (which is due to the urgency with the
good experience of a physician not always used even in intensive care units). The implantation of central venous catheter by the same approach also gives information on the
central venous pressure in the right heart cavities and on
any hypovolemia which directs and determines a further
treatment27. The Swan-Ganz catheter may be implanted and
placed by the same venous access at the time of hospitalization in the intensive care unit via the tricuspid orifice into
the pulmonary artery, with a short-term obstruction of the
artery as to measure the pulmonary capillary pressure that
is equal to the pressure in LA (normal up to 10mmHg). This
is how we obtain an assessment of the condition of the LV
myocardium, telediastolic pressure in the LV as an expression of telediastolic volume and contractility. Regarding this
procedure, tricuspid valve may be damaged and recently
there are controversies about whether it improves survival.
Here we present a modern approach to the treatment of
threatening cardiac tamponade, which is performed in
developed countries and requires expertise and material investment in the EMS equipment.
Cardiologia CROATICA
DijagnostiËke metode kod tupe i oπtre traume
prsnog koπa (u hospitalizaciji)
Diagnostic methods for blunt and sharp chest
trauma (in hospitalization)
1. Radioloπkim pregledom prsnog koπa otkriva se pneumotoraks, pneumoperikard, hemotoraks te medijastinalno proπirenje zbog hematoma. Konvencionalna snimka i profil prsnog koπa ne moæe prikazati miokardnu kontuziju, valvularno
oπteÊenje, niti dokazati postojanje manjeg perikardijskog
sadræaja. Perikardijski izljev tek u koliËini veÊoj od 200 mL
kod snimanja u leæeÊem poloæaju “nalije se” na gornji dio velikih æila i daje sjenu sliËnu trapezu. U projekciji stojeÊi daje
“sjenu srca kruπkolikog izgleda — praznih pluÊa”.
2. Angiografija koronarnih arterija primjenjuje se rijetko, ako
stanje unesreÊenog dopuπta u nerazjaπnjenoj hipotenziji, a
u korigiranoj hipovolemiji da se otkrije oπteÊenje intime, prisutno neposredno poslije traume te u kasnijem tijeku tromboza, okluzija koronarnih arterija, disekcija ili aneurizmatsko
proπirenje.
3. EKG zapis kod traume, osim aritmija, pokazuje druge nespecifiËne nalaze ST-segmenta. Nalaz promjena ST-segmenta i T-vala je sliËan za perikardno-miokardno oπteÊenje
kod tupe traume nalazu nekih oblika srËanog infarkta, miokardne ishemije, lezije. Kod penetrantne traume prisutni su
ËeπÊe znakovi nekroze q- i QS- zupci.
4. Lijevom i desnom kateterizacijom srca dobiju se detaljne
informacije o stanju srËanih valvula, funkciji, intrakardijalni
tlakovima Pretraga ne spada u red prvog dijagnostiËkog izbora i treba biti dobro indicirana. U velikom hematoperikardu,
koji nije tretiran terapijskom perikardiocentezom, niti se ima
moguÊnosti kiruπki intervenirati, veÊ Swan-Ganzovim kateterom, dobiju se informacije o tlakovima desne strane srca.
5. Transtorakalna ehokardiografija (TTE) je visoko osjetljiva
i specifiËna pretraga za otkrivanje i malih koliËina perikardijskog sadræaja28. Nije specifiËna za diferencijaciju sadræaja
— eksudat, transudat (hidroperikard), hemoperikard, hiloperikard (ruptura duktusa toracikusa) i manje je osjetljiva za otkrivanje manjih ruptura, laceracija miokarda i perikarda. Diferencijalna dijagnoza navedenih kvaliteta perikardijskog
sadræaja moguÊa je samo dijagnostiËkom perikardiocentezom uz pomoÊ ultrazvuka i potom dopunskim analizama.
Meutim, ta se pretraga (u tu svrhu) rutinski ne primjenjuje.
DijagnostiËka perikardiocenteza uz pomoÊ ultrazvuka srca u
maloj koliËini perikardijskog sadræaja inaËe je visoko riziËna,
makar je izvodio kardiolog, kardiokirurg (opisan je 2012. godine sluËaj bolesnice kod koje je u jednom ameriËkom sveuËiliπnom centru u dijagnostiËkoj perikardiocentezi uËinjena
perforacija DV, kod malog perikardijalnog sadræaja25).
6. Transezofagijska ehokardiografija je osjetljivija metoda od
TTE u procjeni nekih parametra, ali u okolnostima prsne
traume, zbog Ëestog oπteÊenja ezofagusa i kraljeænice, nije
prikladna za primjenu.
7. Magnetna rezonancija (MR) srca je dobrodoπla dijagnostiËka metoda u mirnom post-traumatskom razdoblju u hospitalizaciji u kirurπkom centru radi razjaπnjenja atipiËnih posttraumatskih prsnih simptoma29. U akutnoj fazi traume zbog
dugog trajanja je praktiËki neprimjenjiva. Osjetljivost MR u
procjeni stupnja kontuzijskog oπteÊenja miokarda, s nekrozom ili bez nje, poremeÊajem kontraktiliteta sa segmentnim
ispadanjima, ocjenom hibernacije πireg perinekrotiËnog
podruËja miokarda te procjenom vijabilnosti miokarda, visoka je i veÊa od TTE.
8. Detaljnija procjena kinetike stijenke miokarda, ukljuËujuÊi
akineziju, hipokineziju te vijabilnost s visokom senzitivnoπÊu
donose nuklearne metode (PET, SPECT).
1. Radiological examination of the chest reveals a pneumothorax, pneumopericardium, hemothorax and mediastinal widening due to hematoma. Conventional image and
profile of the chest can not show myocardial contusion, valvular injury, or prove the existence of a minor pericardial
fluid. Pericardial effusion only in quantities over 200 mL in
case of recording in the lying position “is poured” onto the
upper part of the large vessels and a provides a shadow
similar to trapeze. In the standing projection it gives a “shadow of the pear-shaped heart — empty lungs”.
2. The angiography of the coronary arteries is applied rarely,
if the condition of the injured in unclear hypovolemia and
corrected hypovolemia allows the detection of the damage
to the intima, present immediately after the trauma and in
thrombosis in the subsequent course, coronary artery occlusion, dissection or aneurysmal expansion.
3. ECG recording in trauma, except in arrhythmia, shows
some other non-specific ST-segment results. The finding of
changes to ST-segment and T-wave is for pericardial-myocardial injury in blunt trauma similar to the finding of some
forms of cardiac infraction, myocardial ischemia, lesions.
Signs of necrosis q-and QS-waves are more often present
in penetrating trauma.
4. Left and right heart catheterization gives us some detailed information on the condition of heart valves, function,
intracardiac pressures. The examination is not considered to
be the first diagnostic choice and should be well indicated.
In case of major hemopericardium, which is not treated by
therapeutic pericardiocentesis, and which is not to be surgically managed, but where we can use Swan-Ganz catheter,
we obtain information on the pressures of the right side of
the heart.
5. Transthoracic echocardiography (TTE) is a highly sensitive and a specific test for detecting even small amounts of
pericardial fluid28. It is not specific for differentiation of the
fluid — exudate, transudate (hydropericardium) hemopericardium, chylopericardium (rupture of the ductus toracicus)
and is less sensitive for detecting minor ruptures, myocardial
and pericardial lacerations. Differential diagnosis of the above indicated qualities of pericardial content can only be made by diagnostic pericardiocentesis under ultrasound guidance followed by additional analyses. However, this test
(for this purpose) is not applied routinely. Diagnostic pericardiocentesis is under heart ultrasound guidance in a small
quantity of pericardial fluid highly risky, although it is performed by a cardiologist, cardiac surgeon (it was described in
2012 case report of a patient with a small pericardial fluid
who in one American university center underwent diagnostic pericardiocentesis resulting in RV perforation25).
6. Transesophageal echocardiography is more sensitive
method than TTE in the evaluation of some parameters, but
in the circumstances of thoracic trauma it is not suitable for
use due to frequent damage to the esophagus and spine.
7. Magnetic resonance imaging (MRI) of the heart is a welcome diagnostic method in a quiet post-traumatic period of
hospitalization in a surgical center for clarification of atypical
post-traumatic thoracic symptoms29. It is practically inapplicable in the acute phase of trauma due to the long duration.
The sensitivity of MRI in the evaluation of the degree of myocardial injury caused by contusion with necrosis or without it,
contractility disorder with segment failure, assessment of hibernation of a wider perinecrotic region of the myocardium
and assessment of myocardial viability is high and higher
than TTE.
Cardiologia CROATICA
2013;8(10-11):342.
9. MSCT i CT prsnog koπa i srca su praktiËki nezaobilazne
metode u hospitalnom razdoblju zbog izvrsne kontrastne
rezolucije i kratkog trajanja pregleda. Daju odgovore o ev.
zahvaÊenosti ostalih organa u prsnom koπu, trbuhu, a moæe
se dodatno i toËno procijeniti ev. zaostalu koliËinu hematoperikarda nakon terapijske perikardiocenteze. Metoda otkriva i minimalnu laceraciju miokarda, perikarda — diskontinuitet njegovih granica, manja udubljenja na perikardu, rupturiranu dijafragmu, hernijaciju trbuπnih organa u prsni koπ i
srËanu luksaciju, strangulaciju srËanih struktura i velikih æila,
strano tijelo ev. zaustavljen u organima, pneumotoraks, pneumoperikard, pleuralne izljeve, interpoziciju pluÊnog parenhima izmeu aorte i pluÊne arterije, izmeu srca i dijafragme
ili i DA i izgonskog trakta DV.
ZakljuËak
Namjera ovog Ëlanka bila je ukazati na poveÊanu incidenciju nastanka tamponade perikarda razliËite etiologije — zbog
penetrantne (oπtre) i nepenetrantne (tupe) ozljede srca, danas ipak najËeπÊe kao posljedica “epidemije” prometnih nesreÊa. Naglaπena je potreba pravodobne prehospitalne dijagnostike i intervencije visokostruËnog i educiranog medicinskog osoblja, po moguÊnosti na mjestu same traume, koja
spaπava æivot unesreÊenog.
Received: 20th Aug 2013
*Address for correspondence: Kardioloπka poliklinika “Bogdan”, Buæanova 4, HR10000 Zagreb, Croatia.
Phone: +385-1-2345-455
8. A more detailed assessment of the kinetics of myocardial
wall, including akinesia, hypokinesia and viability with high
sensitivity is made by nuclear methods (PET, SPECT).
9. MSCT and CT of the chest and heart are practically unavoidable methods in the in-hospital period due to excellent
contrast resolution and short duration of the examination.
They provide answers about other organs potentially affected in the chest, abdomen, and residual amount of hemopericardium after therapeutic pericardiocentesis is to be additionally accurately assessed. The method detects even minimal laceration of the myocardium and pericardium — discontinuity of its borders, smaller recesses in the pericardium, ruptured diaphragm, herniation of abdominal organs
into the chest and cardiac luxation, strangulation of cardiac
structures and large vessels, a foreign body potentially stopped in the organs, pneumothorax, pneumopericardium,
pleural effusions, interposition of the lung parenchyma between the aorta and pulmonary artery, between the heart
and the diaphragm, or both RA and RV outflow tract.
Conclusion
The purpose of this Article was to point to an increased incidence of development of pericardial tamponade of various
etiology — caused by penetrating (sharp) and non-penetrating (blunt) cardiac injury, today still usually as a result of
“epidemic” of car accidents. The need for prompt pre-hospital diagnosis and intervention by highly qualified and trained
medical personnel, preferably on the spot of the trauma, that
saves life of an injured person is emphasized.
Fax: +385-1-2345-466
E-mail: [email protected]
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